Adolescent Disc Herniation: Conservative or surgical treatment?
The patient is a 17-year-old male who presents with a 6-month history of increasing low back and buttock pain. He sustained a twisting injury when hit by another soccer player and landing awkwardly during a game. He denied any pain below his knee. There was no loss of bowel or bladder control. He is a nonsmoker, 11th grader at local high school. He has no medication allergies and no additional medical problems.
Well-nourished, well-developed male. He stands 6'2'' and weighs 178 pounds. He is normocephalic, alert, and oriented times three. He has a normal plantigrade gait. He is able to walk on his heels and toes, and he is able to squat without difficulty. ROM in the lumbar spine is within normal limits except for forward flexion. He has mild paraspinal muscle spasm in the lumbar area without soft tissue swelling ecchymosis or erythema. In the seated position, his reflexes are absent but symmetrical both patellae, 2+ and symmetrical both ankles. He has a negative Babinski sign and a negative flip test bilaterally. Light touch is intact L4 through S1.
Sagittal T1 and T2 MRI with axial view through L5-S1 (Figures 1, 2). MRI following visit demonstrates herniated nucleus pulposis on the right at L5-S1 (Figures 3, 4).
L5-S1 herniated nucleus pulposus with referred pain to the right buttock.
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The patient was initially treated with a combination of pharmaceuticals (non-steroidal anti-inflammatory, muscle relaxers), physical therapy, and activity alteration (no weight lifting or high impact activities). Following a 6-week course of treatment, the patient continued to have primarily right-buttock pain and, on further questioning, mild right-calf discomfort. A selective nerve root block on the right at L5-S1 produced complete relief of the calf and buttock pain. Continued therapy and gradual resumption of activities was successful in returning patient to full activity over a 2-month time course.
At ten months status post initial injury, the patient experienced a recurrence of symptoms. Repeat MRI demonstrated no significant change in HNP at L5-S1 on the right. Repeat selected nerve root block provided temporary relief. Following discussion with the patient and his parents, an outpatient minimally invasive microdiscectomy via 18-millimeter tube was performed on the right at L5-S1.
Post-treatment AP and lateral plain X-rays. Note right L5-S1 laminotomy (Figures 5, 6).
The patient is now 4-months post-treatment and resuming full activity, including basketball for his high school team, without buttock or calf pain.
This is a case of a 17-year-old male athlete who sustained a disc herniation in the lumbar spine at the L5-S1 level. Certainly, conservative treatment is the most appropriate as the initial treatment for these types of conditions, as long as there is no urgent neurological deterioration. In this case, conservative treatment in the forms of anti-inflammatory medications, physical therapy, and activity modification was absolutely appropriate. In the majority of patients, this will alleviate the symptoms and allow for recovery with significant relief of pain. After 6 weeks of continued symptoms, despite the conservative care, the physician recommended a selective root block injection at the level of the disc herniation. This initially appeared to resolve the symptoms and allowed the patient to return to his activities. These injections are also very appropriate at this time, and again, many patients will respond favorably as in this case.
Unfortunately, the symptoms recurred, and the MRI again revealed the herniated disc at the L5-S1 level, which was unchanged from the prior MRI. This is also a very common scenario and implies that the initial treatments, while effective for symptomatic relief, did not result in resolution of the actual anatomical problem of the disc bulging outward against the nerve and putting pressure on the nerve, resulting in the symptoms. After counseling the patient and his family, the decision for surgery was appropriate after failure of conservative care. The choice of the microdiscectomy was appropriate in this situation, and I would expect the patient to do quite well. I think the management of this case was very appropriate, conservative initially, and surgery only after the failure of the non-operative treatments.